February 2015 (Electronic distribution February 4, 2015 ...

1 February 2015 . ( electronic distribution February 4, 2015 ). Urine drug testing policy, effective Dec. 15, 2014. Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy (Urine Drug Testing Including Pain Management and Substance Abuse Monitoring) became effective Dec. 15, 2014. This new policy addresses the overutilization of quantitative/confirmatory urine drug testing as a routine screening tool. With few exceptions, this policy prohibits the routine use of quantitative/confirmatory testing as being not medically necessary. The most prominent exception being when a patient tests positive on a qualitative test and the physician determines it is medically necessary for treatment decisions to know the quantity of the drug in the patient's system. BCBSTX encourages providers to review this new policy as soon as possible to ensure they only submit claims that are consistent with this new policy.

2 The BCBSTX Special Investigations Department will be monitoring provider compliance and may initiate investigations as appropriate. Independently contracted providers found billing inappropriately, contrary to this policy, may be subject to overpayment refunds and other actions as deemed appropriate based on the circumstances of each case. Please visit the Standards and Requirements/Medical Policy section of the BCBSTX. provider website for access to up-to-date medical policy information. The BCBSTX Medical Policies are for informational purposes only and are not a replacement for the independent medical judgment of physicians. Physicians are encouraged to exercise their own clinical judgment based on each individual patient's health care needs. Some benefit plans administered by BCBSTX, such as some self- funded employer plans or governmental plans, may not utilize BCBSTX Medical Policy.

3 Members should contact their BCBSTX Customer Service department for specific coverage information. 2014 HEDIS antidepressant medication management results The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans, and it measures performance on important dimensions of care and service, including Behavioral Health. Because so many plans collect HEDIS data and the measures are so specifically defined, HEDIS makes it possible to compare performance among health plans. The Antidepressant Medication Management HEDIS metric includes members who: Are 18 years of age or older, Blue review , February 2015 1. Have been diagnosed with major depression, Were newly treated with antidepressant medication, and Remained on an antidepressant medication treatment.

4 To evaluate if members are receiving the maximum benefit from an initiated antidepressant medication regimen, two rates are reported: Effective acute phase: Those who stayed on an antidepressant for at least 12. weeks (84 days). Effective continuation phase: Those who stayed on an antidepressant for at least 6 months (180 days). What were the Blue Cross and Blue Shield of Texas (BCBSTX) member results? HEDIS measurements are calculated annually and compared to national averages. For patients who stayed on an antidepressant for at least 12 weeks the 2014 national average was percent, and the average for BCBSTX members was percent. For patients who stayed on an antidepressant for at least six months the 2014 national average was percent, and the average for BCBSTX members was percent. What is BCBSTX doing to help?

5 We have provided an educational article to members about the importance of staying on antidepressant medication, and we continue to work with our pharmacy and reporting departments to develop programs to assist members with their medications. If you have a patient you believe is not fully compliant with an antidepressant regime and you believe therapy would also be beneficial, we can help. You or the patient can contact us via the BCBSTX number on the back of the member's ID card. We can help them locate a behavioral health therapist, enroll them in one of our case management programs, or help coordinate care so that the patient is more successful with their antidepressant medication regime. For additional information, visit the Clinical Resources/Behavioral Health Care Management Program section of the BCBSTX provider website.

6 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). ClaimsXtenTM updates First quarter 2015 . Blue Cross and Blue Shield of Texas (BCBSTX) reviews new and revised Current Procedural Terminology (CPT ) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson and are not considered changes to the software version. BCBSTX will normally load this additional data to the BCBSTX claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSTX Provider website. Advance notification of updates to the ClaimsXten software version ( , change from ClaimsXten version to ) will continue to be posted on the BCBSTX provider website. Blue review , February 2015 2.

7 Beginning on or after April 20, 2015 , BCBSTX will enhance the ClaimsXten code auditing tool by adding the first quarter 2015 codes and bundling logic into our claim processing system. The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review , code auditing and payment administration, which we believe results in improved performance of overall claims management. BCBSTX will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI). NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of '0 indicates that NCCI associated modifiers cannot be used to bypass the edit.

8 " BCBSTX will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added. To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSTX's code-auditing software. Refer to the BCBSTX provider website at for additional information on gaining access to C3. For more details regarding ClaimsXten, including answers to frequently asked questions, refer to the Education & Reference/Provider Tools/ Clear Claim Connection page on our provider website. Information also may be published in upcoming issues of Blue review .

9 Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered. ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services. CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. BlueCompareSM for physicians Blue Cross and Blue Shield of Texas (BCBSTX) evaluates the performance of Blue Choice PPOSM network physicians in 18 measured specialties on Evidence Based Measures (EBM) and Physician Cost Assessment (PCA) as compared to peers in the same Working Specialty.

10 Consistent with national guidelines, a cost-efficiency assessment is only performed if the specialty-specific, quality-related criteria are met. This years' evaluation is underway and we will mail the affected physicians a communication with instructions for accessing their Performance Reports in a secure Blue review , February 2015 3. online portal (if applicable). BCBSTX also has two additional transparency programs that provide quality related performance information on the National Doctor & Hospital FinderSM and the BCBSTX Provider Finder . The Physician Quality Measurement Program (PQM) collects data on nationally endorsed physician quality measures, Evidence Based Measures. Physician practices PQM results shown on the physician's BlueCompare 2015 EBM Summary Report will be displayed on the National Doctor & Hospital Finder and the BCBSTX Provider Finder effective third quarter of 2015 .